FROM ZERO TO HERO DEVELOPING A BEST PRACTICE IN VAP … · • ETT: Covidien Taperguard EVAC •...

FROM ZERO TO HERODEVELOPING A BEST PRACTICE IN VAP-PREVENTION

November 2016dr. Walter Swinnen

DISCLOSURE

NONE

12

beds

1200 patients / year

Mixed medical/surgical

ICU

Closed type

6 intensivists

25 FTE nurses

0,6 FTE physio

1 FTE logistics

5,4 %

Mortality

0,36

SMR (SAPS-2)

1,4 VAP

/ 1000 VD

5 jan 2011

Last cathetersepsis

CORE DATAICU-azSB

WHAT'S SO SPECIAL ABOUT VAP?

SPECIAL CIRCUMSTANCESSpecial patients

Special environment

After a few days

of mechanical ventilation

SPECIAL CIRCUMSTANCES

SPECIAL CONSEQUENCES

SPECIAL CONSEQUENCES

Search date Nov 21th 2016

BIJZONDERE GEVOLGENSPECIAL CONSEQUENCES

21,720,7

17,9

15,614

1615,2

13

15,8

11,812,7

17,9

12,5

8,9

12,9

7,2 7,38,6

6,3

9,9

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Institute Public HealthNavigator

TO IMPROVE DIFFICULT IS

TO IMPROVE IS DIFFICULT

≠

TO IMPROVE IS DIFFICULT

NOTHING LASTS FOREVER…9 QUALITY INDICATORS OF ESICM 2012

• ICU OK with okay with national legislation

• Intensivist 24/24 available

• Multidisciplinary consultation

• Incident reporting

• Standardized hand over at discharge

• Standardized Mortality Ratio (SMR)

• Readmission < 48u after discharge

• Unplanned extubations

• Catheter associated blood stream infections

26,9

36,8

2,64,6

3,21,4

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

VAP > D2 / 1000 ventilatiedagen

FROM ZERO TO HERO

FROM ZERO TO HERONOT THAT EASY !

• Exclude patients with LOS < 48h• Stop measuring 48h after extubation• Count patients with duration of MV < 48h• Measure continuously, or:

– You lose the attention of your collaborators– You lose knowledge of registration & definitions

VAP incidence = VAP (n) * 1000

ventilator days (n)

UNIFORM DEFINITIONS

Peer review of possible VAP’s:

– Promote identification

– Data manager checks definitions

– 2 peers review data

– Majority wins

USE UNIFORM DEFINITIONS

26,9

36,8

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

EVOLUTION VAP ICU-azSB2000: FIRST FEEDBACK

• Better adherence to scoring guidelines by:– Sensitize the intensivists

– Training in correct use of definitions

Data transfer to IPH

26,9

36,8

29,3

26,7

18,2

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

• Better adherence to scoring guidelines by:– Sensitize the intensivists

– Training in correct use of definitions

• Better results:– Hawthorne effect?

– Real improvement?

– Face lift? i.e. false negatives?

• 2004: validation study IPH Q1-2001– Sensibility: 69,1% (benchmark: 53,7%)

– Specificity: 96,1%


Sto

p f

eed

bac

k

EVOLUTION VAP ICU-azSB2001-2003

New

HEL

ICS-

def

inti

on

26,9

36,8

29,3

26,7

18,2

12,6

18,6

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


• Dark ages:– No feedback IPH

– Calculate results with NISH-software

• 2004: aspiration technique– Training

– Standing order

• S2-2004 & S1-2005:– Test subglottic suctioning

– Result: negative


26,9

36,8

29,3

26,7

18,2

12,6

18,6

10,2

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


EVOLUTION VAP ICU-azSB2006

Sto

p d

atat

ran

sfer

IPH

26,9

36,8

29,3

26,7

18,2

12,6

18,6

8,2

20,5

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


REVIEW OFEVIDENCE

TRAINING ICU-STAFFW/ NEW STUFF

DATACOLLECTIONREPORT DATA

EVERY Q TO STAFF

26,9

36,8

29,3

26,7

18,2

12,6

18,6

8,2

20,5

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


• New new stuff:– Closed airway suctioning

– MDI-port

– ETT with PU-cuff

– Manual cuff pressure measurement

• Poster in every room

26,9

36,8

29,3

26,7

18,2

12,6

18,6

8,2

20,5

22,6

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


• Nurses’ observations: closed suction doesn’t work

• New focus: micro-aspiration

Subglottic suctioning• Evacuation of secretions

above the cuff

• Manual vs. automatic

• Intermittent vs. continu

Cuff• Design: barrel vs. cylindric

vs. tapered

• Material: PVC vs. PU vs. silicone

Cuff pressure

• Intermittent vs. continuousmeasurement

• Automatic vs. manual correction

HOW TO TACKLE MICRO ASPIRATION ?

MICRO ASPIRATION

5 min

72 h

26,9

36,8

29,3

26,7

18,2

12,6

18,6

8,2

20,5

22,6

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


X

26,9

36,8

29,3

26,7

18,2

12,6

18,6

8,2

20,5

22,6

10,1

7,7

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


26,9

36,8

29,3

26,7

18,2

12,6

18,6

8,2

20,5

22,6

10,1

7,7

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


• New oral care materials:– Chlorhexidine 0,2%

– Oral care system with social control


26,9

36,8

29,3

26,7

18,2

12,6

18,6

8,2

20,5

22,6

10,1

7,7

11,4

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

• Project Fed Dpt Health, cell Quality

• Development Belgian VAP-bundle

• Synergistic combination of ‘best practices’ that improve care (1+1=3).

• Evidence based & 'standard of care’.

• Very clear, measurable elements: yes / no answers.

• All the elements in the bundle must be carried out together: non-compliance with one element =non-compliance of the complete bundle.

BUNDLE

> 30° elevation Sedation stop? Cuff pressurecontrol

Oral Care Chlorhexidine

Optional: Subglotticsuctioning

BELGIAN VAP-BUNDLE v2012

azSB VAP-BUNDLE v2012

024681012141618202224262830

0%10%20%30%40%50%60%70%80%90%

100%

Totale compliantie Gemiddelde compliantie Aantal pneumoniën /1000 dagen

COMPLIANCE azSB 2013

97,3

99,9

99,997,3

99,9

0

20

40

60

80

100Total

30° elevation

Sedation vacationOral Care

Cuff pressure control

26,9

36,8

29,3

26,7

18,2

12,6

18,6

8,2

20,5

22,6

10,1

7,7

11,4

2,64,6

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


97,3

99,9

99,997,3

99,90

20

40

60

80

100Total

30° elevation

Sedationvacation

Oral Care

Cuff pressurecontrol

26,9

36,8

29,3

26,7

18,2

12,6

18,6

8,2

20,5

22,6

10,1

7,7

11,4

2,64,6

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


• Sedation protocol with RASS

26,9

36,8

29,3

26,7

18,2

12,6

18,6

8,2

20,5

22,6

10,1

7,7

11,4

2,64,6

3,21,4

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


26,9

36,8

29,3

26,7

18,2

12,6

18,6

8,2

20,5

22,6

10,1

7,7

11,4

2,64,6

3,21,4

0

5

10

15

20

25

30

35

40

99 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

IPHNAVIGATOR

azSB

EVOLUTION VAP IZ-azSB1999-2015

CRITICISM

COSTS OF INNOVATION

You

You’ll want to be here

COST

For the hospital• ETT: 200x

– € 20 vs. € 2

• Cuff controller: 12x– € 1.440 vs. € 141

• Suction pumps: 12x– € 650– Reservoirs 200mL: € 3– Reservoirs 1L: € 1

Total: € 28.080Additional expenses: € 21.080

BENEFIT

For society

3 VAP’s = € 30.000 benefit = cost neutral

COST-EFFECTIVE ?

22

18

7

5

8

23

21

16 16

20

18 18

23

8

6

7 8 9 10 11 12 13 14 15

n VAP obs n VAP exp IPH

COST:€ 80.000

IMPACT OP DE UITGAVEN

SAVINGS:€ 660.000

COST-EFFECTIVE ?

18

6

32

6

12

816

103635

9

346

20

45

8 10

68

45

6

12

51

2410

22 88

9

3612

6

9

128

30

6

6

199

9106

156 8

6

9

9

1011

8

12

2815

7

11

8

18

8

7

6

9

8

15

12

12

10 12

67 accredited ICU’s, 1152 beds

IMAGINE…

REPRODUCIBILITY ?

azSB

• ETT: Teleflex Isis

• Subglottic suctioning, no data about technique

• Non-continuous cuff pressure measurement

• > 30° elevation head end bed

• Oral care with chlorhexidine

• Daily reassessment of sedation goals

• ETT: Covidien Taperguard EVAC

• Intermittent subglottic suctioning pump

• Continuous cuff pressure measurement

• > 30° elevation head end bed

• Oral care with hexetidine

• No sedation goals

Crit Care Med 2015; 43(1):22-31

22,6 7,7 VAP/1000 VD

20 9,8 VAP/1000 VD

EVERY ADVANTAGE HAS ITS DISADVANTAGE

Johan Cruyff, reversed

GEMOTIVEERDE DEELNEMERS

MEAN LENGTH OF STAY

4,28

3,973,87

3,59 3,53 3,50 3,56

3,323,43

3,37

2,50

3,00

3,50

4,00

4,50

5,00

6 7 8 9 10 11 12 13 14 15

BED OCCUPANCY 2015

DISADVANTAGES

Calender day based

3961 d

90,4 %

Exact

(minute based)

2763,63 d

63,1 %

CONSEQUENCES

STAFF REDUCTION INCOME DROP

X

CONSEQUENCES

BUT, IF YOU ASK ME …

Credits to…Dr. Koch

Dr. Temmerman

Dr. Sarens

Dr. Pannier

Dr. Mignolet

Aafke

Annelies

Pascal

Chris

Serge

Stefaan

MiraDavid

Kathleen

AstridSofie

VickyMarc

Gudrun

HelenaMarijke

Kelly

Thijs

Paul

CindyChloé

Mieke

Karen

Guido

Sonja

Evelien

Leen

MarijkeV

Hendrik Dr. Swinnen

Maria

RitaMariaken

Marlies

FROM ZERO TO HERO DEVELOPING A BEST PRACTICE IN VAP … · • ETT: Covidien Taperguard EVAC •...

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Transcript of FROM ZERO TO HERO DEVELOPING A BEST PRACTICE IN VAP … · • ETT: Covidien Taperguard EVAC •...