Transcript Monitoring Patients on Mechanical Ventilation: A New Paradigm

Monitoring Patients on Mechanical
Ventilation: A New Paradigm
Terri Conner, Ph.D.
Nybeck Analytics
May 2012
A Review of Select Literature
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Gerard et al. Efficacy and safety of a paired sedation and
ventilator weaning protocol for mechanically ventilated patients
in intensive care (Awakening and Breathing Controlled Trial): a
randomised controlled trial. Lancet 2008;371:126
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Klompas et al. Multicenter evaluation of a novel surveillance
paradigm for complications of mechanical ventilation. Plos One
2011;6:e18062
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Klompas et al. Rapid and reproducible surveillance for
ventilator-associated pneumonia. Clin Infect Dis 2012;54:370
Girard et al. Efficacy and Safety of Paired
Sedation and Ventilator Weaning Protocol
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Purpose: Assess protocol that pairs SAT and SBT
Vanderbilt Univ of Medicine Coordinating Center
supervised 4 large medical centers
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St Thomas Hospital (Nashville)
Univ of Chicago Hospitals (Chicago)
Hospital of Univ Penn (Philadelphia)
Penn Presbyterian Med Ctr (Philadelphia)
336 mechanically ventilated pts randomly assigned
to receive daily SAT/SBT or sedation per usual care
plus daily SBT
SAT: spontaneous awakening trial; SBT: spontaneous breathing trial
Methods
Endpoints
1:Number of ventilator free days
2:
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time to discharge from ICU, from hospital;
all-cause 28 day mortality;
1 yr survival;
duration of coma/delirium
Results
Results
Results
Klompas et al. Multicenter Evaluation
of a Novel Surveillance Paradigm
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Purpose: To compare outcomes for VAC and
CAP
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Time for surveillance
Duration of mechanical ventilation
LOS in ICU and hospital
Mortality
Methods
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Three academic medical centers
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Brigham and Women’s (Boston)
Ohio State Univ Med Ctr (Columbus)
LDS Hospital (Salt Lake City)
Retrospective review: Each hospital
randomly selected 100 pts vented for 2-7
days and 100 pts vented >7 days
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Each patient was assessed for VAC and for VAP
Definitions
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VAC
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PEEP and FiO2 per day recorded
VAC defined as an increase in a patient’s daily minimum
PEEP by 2.5 cm H2O sustained for >=2 days or an increase
in the daily minimum FiO2 by >=15 points sustained for >=2
days after a minimum of 2 days of stable or decreasing daily
minimum PEEPs and FiO2s respectively
VAP
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NHSN definition, determined by 1-3 IPs
Results
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A total of 597 patients with 6,347 vent days
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Of these 9% met VAP definition (8.8 per 1000
vent days) and 23% met VAC definition (21.2 per
1000 vent days)
Among the two hospitals that recorded review
time
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VAP reviewer required 260 hours to assess 400 patients
(mean 39 mins per patient)
VAC reviewer required 12 hours to assess 400 patients
(1.8 mins per patient)
Comparison of Outcomes
Matched Patient Outcomes
Sensitivity and Specificity of VAC
relative to VAP
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Sensitivity 56% (95% CI 43-69%)
Specificity 95% (95% CI 92-97%)
Patients who met criteria for both VAC and
VAP had the longest LOS, those who met
criteria for only 1 of 2 had similar
intermediate LOS, and those who were
negative for both had the shortest LOS.
Comment
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Many observers have questioned the validity
of comparing VAP rates between hospitals as
well as the clinical significance of reports of
‘zero’ rates
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In this study, among patients ventilated for 7 days
or less, the observed VAP rates varied from 0 to
4% but VAC rates varied only 7 to 9%, suggesting
a measure that is both more uniform and able to
detect complications in populations with
ostensibly zero VAPs
Klompas et al. Rapid and Reproducible
Surveillance for VAP
Data Collection
Results
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Review with conventional definition took 39
mins per patient while, with streamlined
definition, review took 3.5 minutes per patient
Both definitions predicted significant
increases in duration of mechanical
ventilation and ICU LOS
Neither definition was associated with
increased hospital mortality
Comment
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Radiographs add little accuracy to the
diagnosis of VAP or prediction of patient
outcomes
Issues
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Change in surveillance methodology
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We need better measurement metrics that better
correlate with patients’ outcomes
Improvement with new rates
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We need to focus on strategies to improve care
for ventilated patients
“Wake Up and Breathe” Quality
Improvement Collaborative
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Leadership from CDC and IHI working with
Epicenters and multiple large medical centers across
the country
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Epicenters are at Harvard (Boston), Duke Univ (Durham),
Washington Univ (St Louis), Univ Chicago (Chicago), Univ
Penn (Philadelphia), Vanderbilt (Nashville)
Their initiative launched April 24, 2012
We have a unique opportunity to act as a ‘second
cohort’ in this initiative to engage front line clinicians,
healthcare specialists, and hospital leadership on
implementing opt-out protocols
Wake Up and Breathe
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The initiative team is
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Working to incorporate SAT and SBT documentation into
existing workflows
Working with new definitions for ventilator-associated
events, slated for NHSN implementation in 2013
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The new definition focuses on complications of mechanical
ventilation
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It is important to monitor and prevent ALL complications in
ventilated patients
– Respiratory deterioration after a period of improvement or
stability can be objectively defined using ventilator settings
Our Goal
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Implement the new definitions to monitor the
success of the paired SAT/SBT initiative
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Address and adopt the new requirements for
surveillance
Demonstrate improvement in patient care
Implications
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Hospitals will have to continue with current
VAP reporting on NHSN, but collect minimal
data for PfP reporting until NHSN definitions
officially change
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Benefits your team as early adopters to be
prepared with changes occur
Strengthens data contributing to value of changes
Consistent data over the PfP time period
Tasks (under development)
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Implement Epicenters’ Wake Up and Breathe
protocol for paired SAT/SBT
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Copy of protocol on the CoP and TCQPS
websites
Training will be provided in late May/June by our
Harvard colleagues
Tasks (under development)
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Complete baseline report
Complete minimal data elements
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Might be able to retrieve some data electronically
Review and Next Steps
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Adoption of the Wake Up and Breathe
initiative is voluntary
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Continuing with NHSN current definitions will
present a problem in 2013
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We are looking for early adopters!
Consider this dilemma in context of PfP
Discuss this initiative with your team and
hospital leadership as soon as possible
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Contact Terri Conner no later than May 25, 2012
with your team’s decision
Categories of Decision
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We are going to continue on as planned and
will move to new NHSN definitions when
required
We are going to begin gathering new data
metrics in anticipation of NHSN changes, but
are not implementing the SAT/SBT protocol
We are going to begin gathering new data
metrics and will plan to implement the
SAT/SBT protocol no later than 2013
VAP Project Manager
Terri Conner, Ph.D.
[email protected]
(512) 796-1099