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How to Improve Patient Outcomes after Mechanical Ventilation
Essential Hospitals Engagement Network
October 1, 2013
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
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SPEAKER INFORMATION
Michele C. Balas, PhD, RN,
APRN-NP, CCRN
Associate Professor
Center of Excellence in
Critical and Complex Care
The Ohio State University
College of Nursing
Alex Ramos, RN, MSN, CCRN
Trauma Operations Manager
Sandra Gonzalez RN, BSN
Director of Trauma, Neurosurgery and
Adult Med/Surg Critical Care Services
Dustin Bierman, RN, MSN
ICU Med/Surg Clinical Coordinator
Luis Martinez, RN, BSN
ICU Med/Surg Manager
ABCDE Team
University Medical Center of
El Paso
John Young, RN, MBA
Improvement Coach EHEN
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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
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EHEN VAP RESULTS (AS OF MAY,
2013)
Summary UHC-Defined VAP Outcome
Numerator: 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).
UHC-Defined VAP/1,000 Discharges
U Chart
Rate
60
UCL
50
40
30
Goal : 40% reduction
(median = 20.04)
20
10
0
LCL
EHEN
kickoff
VAE
Def.
change
Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May10 10 10 10 10 10 10 10 10 10 10 10 11 11 11 11 11 11 11 11 11 11 11 11 12 12 12 12 12 12 12 12 12 12 12 12 13 13 13 13 13
Subgroup 22.2 23.7 23.7 32.6 36.2 32.3 33.1 29.3 54.8 42.7 35.1 33.2 36.3 42.5 27.1 37.9 28.4 46.5 39.5 36.6 23.9 24.1 34.5 36.9 38.4 28.2 35.0 34.7 34.0 39.4 27.5 36.9 28.4 27.1 29.3 28.8 22.9 42.0 33.5 32.5 34.5
Center
33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4 33.4
UCL
56.1 56.8 55.2 55.0 55.2 54.9 55.7 56.2 55.4 55.2 55.3 55.2 54.7 56.5 55.3 56.2 56.5 56.6 56.1 55.3 56.1 55.4 56.8 54.5 55.8 56.4 54.8 56.8 55.0 56.6 56.2 55.4 56.5 55.3 55.0 56.7 54.8 56.3 55.3 56.1 56.8
LCL
10.7 10.0 11.6 11.8 11.6 11.9 11.1 10.6 11.4 11.6 11.5 11.6 12.1 10.3 11.5 10.6 10.3 10.2 10.7 11.5 10.8 11.4 10.0 12.3 11.0 10.4 12.0 10.0 11.9 10.2 10.7 11.4 10.3 11.5 11.9 10.1 12.0 10.5 11.5 10.7 10.0
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Improving PatientCentered 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 Adamshttp://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 IssuesICU Acquired Delirium & Weakness
• Profound & emerging public health
threat
•
•
•
•
Common
Lethal
Disabling
Persistent
The IssuesICU Acquired Delirium & Weakness
Delirium
Weakness
•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
• 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);
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
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
•Jackson et al., Anesthesiology Clinics, 2011; Ehlenbach, Jama,
60
p=.03
50
40
(predicted mean T-score)
•½ of all ICU survivors
Cognitive Function at 12 months
Delirium & New Onset Cognitive
Impairment
30
20
10
0
0
5
1
0
1
5
Delirium
Days
2
0
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
•
Immobility/prolonged
bed rest
•
•
Mechanical
Ventilation
Non-Modifiable
• Age
• Severity of illness
• Comorbidities
• Pre-existing
CI/dementia
Uncontrolled pain
• Drug/ETOH
Sleep deprivation
withdrawal
Potential SolutionABCDE 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)
•Kress et al. (2003)
NEJM
AJRCCM
tests
FU
• Fewer diagnostic
• No difference in
• Complications
• Mortality
• Hospital LOS
•32 patients 6 month
•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
• RCT, single center, N=300
• Respiratory care-driven weaning protocol
(Ely et al. 1996 NEJM)
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
•
•
VFDs (3 days)
•
•
•
NNT-7 to save a life at 1
year
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 trial
Both 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
What Does the Evidence Tell Us?
Delirium Monitoring/Management
Morandi A, et al. Intensive Care Med. 2008;34:19071915.
• CAM-ICU
• ICDSC
What Does the Evidence Tell Us?
Early Exercise/Mobility
• Early PT and OT in Mechanically
Ventilated ICU Patients
Schweickert WD, et al. Lancet. 2009;373(9678):1874-1882.
PT/OT with DSI n = 49
16
DSI alone n = 55
Median Time (days)
14
13.5
12.9
12
10
7.9
8
6.1
6
4
4
2
5.9
3.4
2
0
Duration of ICU
Delirium
Mechanical
Ventilation
ICU LOS
Hospital LOS
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 Safety Screen
•
•
•
•
•
•
•
No agitation
Oxygen saturation ≥ 88%
FiO2 ≤ 50%
PEEP ≤ 7.5 cm H2O
No myocardial ischemia
No vasopressor use
Inspiratory efforts
SBT Failure Criteria
•
•
•
•
•
•
Respiratory rate > 35/min
Respiratory rate < 8/min
Oxygen saturation < 88%
Respiratory distress
Mental status change
Acute cardiac arrhythmia
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
Walking
A
Short
Distance
Standing at
bedside
and
sitting 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 CAMICU/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 EasyWhat 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;34:374380.
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.
Barriers to Daily Sedation
Interruption
(Survey of 904 SCCM members)
Increased device removal
Poor nursing acceptance
Compromises patient comfort
Leads to respiratory compromise
Difficult to coordinate with nurse
No benefit
#1 Barrier
Leads to cardiac ischemia
#2 Barrier
#3 Barrier
Leads to PTSD
0
10
20
30
40
50
60
70
Number of respondents (%)
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.
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
Q&A
44
UNIVERSITY MEDICAL CENTER OF EL
PASO
45
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
Q&A
47
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.
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THANK YOU FOR ATTENDING!
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