How to Improve Patient Outcomes after Mechanical Ventilation Essential Hospitals Engagement Network...
-
Upload
kelley-mcdowell -
Category
Documents
-
view
216 -
download
0
Transcript of How to Improve Patient Outcomes after Mechanical Ventilation Essential Hospitals Engagement Network...
How to Improve Patient Outcomes after Mechanical VentilationEssential Hospitals Engagement Network
October 1, 2013
2
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
3
CHAT FEATURE
The chat tool is available to ask questions or comments at anytime during this event.
4
RAISE YOUR HAND
To raise your hand – you must be in the “Participants” pane.
Your line will be un-muted to ask your question. Once your question has been answered, plus un-raise your hand.
5
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
6
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
7
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).
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Subgroup
22.222222222222
2
23.722627737226
3
23.734177215189
9
32.608695652173
9
36.220472440944
9
32.258064516129
33.057851239669
4
29.310344827586
2
54.750402576489
5
42.721518987341
8
35.087719298245
6
33.175355450237
36.253776435045
3
42.477876106194
7
27.070063694267
5
37.931034482758
6
28.419182948490
2
46.511627906976
7
39.451114922813
36.565977742448
3
23.890784982935
2
24.115755627009
6
34.545454545454
6
36.927621861152
1
38.397328881469
1
28.218694885361
6
34.954407294832
8
34.671532846715
3
34.003091190108
2
39.426523297491
27.538726333907
1
36.918138041733
6
28.368794326241
1
27.070063694267
5
29.320987654321
28.828828828828
8
22.865853658536
6
41.958041958042
33.546325878594
2
32.478632478632
5
34.482758620689
7
Center
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
33.409982415798
7
UCL
56.081544547108
2
56.834416043325
7
55.222251120538
4
55.018075625201
9
55.170665075821
6
54.901589098922
8
55.703658713790
7
56.179057092308
2
55.414587472632
4
55.222251120538
4
55.309049190107
3
55.205015030367
7
54.722285492905
1
56.479321594959
6
55.291606680948
5
56.179057092308
2
56.520261004588
8
56.602797976558
1
56.120399009429
1
55.274205784148
6
56.062191951066
4
55.396891768075
9
56.791787375373
9
54.484859187296
3
55.815034975522
6
56.438598987428
8
54.786966379332
7
56.834416043325
7
54.967921376042
2
56.623570766714
8
56.159453924940
4
55.379238686665
2
56.499764079413
1
55.291606680948
5
54.951280741404
8
56.686225640051
5
54.819528445370
7
56.337728521932
3
55.326533477742
3
56.081544547108
2
56.770560130907
7
LCL
10.738420284489
2
9.9855487882717
4
11.597713711059
11.801889206395
6
11.649299755775
9
11.918375732674
7
11.116306117806
7
10.640907739289
3
11.405377358965
1
11.597713711059
11.510915641490
1
11.614949801229
8
12.097679338692
4
10.340643236637
9
11.528358150648
9
10.640907739289
3
10.299703827008
6
10.217166855039
4
10.699565822168
4
11.545759047448
9
10.757772880531
11.423073063521
5
10.028177456223
5
12.335105644301
1
11.004929856074
9
10.381365844168
7
12.032998452264
8
9.9855487882717
4
11.852043455555
3
10.196394064882
7
10.660510906657
1
11.440726144932
3
10.320200752184
3
11.528358150648
9
11.868684090192
6
10.133739191545
9
12.000436386226
8
10.482236309665
2
11.493431353855
1
10.738420284489
2
10.049404700689
8
5
15
25
35
45
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
10
20
30
40
50
60
0 5 10
15
20
Delirium Days
Cog
nitiv
e F
unct
ion
at 1
2 m
onth
s(p
red
icte
d m
ean
T-s
core
)
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
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
What Does the Evidence Tell Us?
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”!!!!!!
What Does the Evidence Tell Us?
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.)
What Does the Evidence Tell Us?
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)
What Does the Evidence Tell Us?
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
What Does the Evidence Tell Us?
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.
What Does the Evidence Tell Us?
Delirium Monitoring/Management
• CAM-ICU
• ICDSC
What Does the Evidence Tell Us?
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
Delirium Monitoring/Management
• 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
Delirium Monitoring/Management
• 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
Delirium Monitoring/Management
•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
Implementation Challenges
• 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
• Knowledge deficits
• Excessive use of registry staff
Is it Worth It?Absolutely
44
Q & A
45
UNIVERSITY MEDICAL CENTER OF EL PASO
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
47
Q & A
48
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.
49
THANK YOU FOR ATTENDING!
• Equity Webinar – October 10 @ 2pm ETBuilding Health Literacy: Essential Steps and Practical Solutions
Speakers: • Dean Schillinger MD, Director, Health
Communication Program, UCSF Center for Vulnerable Populations
• Michele Edwards , NP Grady Heart Failure Clinic
• Evaluation: When you close out of WebEx following the webinar a yellow evaluation will open in your browser. Please take a moment to complete. We greatly appreciate your feedback!
• Essential Hospitals Engagement Network website: http://tc.nphhi.org/Collaborate