NYSPFP HAI (VAP) and the Patient

HAI (VAP) and the patient
Alison S. Clay, MD, FCCP
Duke University
Healthcare Team Training
Disclosures
• This is my personal experience, told with the
support of my administration
• Although I am a physician, I am a fierce
patient advocate
• I believe teamwork is the only way to innovate
in healthcare
– I do consulting work with healthcareteamtraining
(HTT)
Goals
• Discuss the impact of HAI on patients
– with particular attention to VAP
– Considering Post-ICU Care Syndrome (PICS)
• Share the impact of Duke initiatives to prevent
HAI, from both the individual’s and system’s
perspectives
The start
On Call
The work up
The diagnosis
Iwashyna, T. Am J Resp and CCM 2012; 186: 302-304
The cost of a port infection
+
1
1
1
1
2
6
X2 ports X2 per day X6 weeks
12
24
>1000
Trajectory of Illness
Trajectory of Illness
Trajectories of Care for patients with PMV
Unroe, M et al. Annals of Internal Medicine 2010; 153:167-175
Trajectory of Illness
A few other discussion points
Delirium Subtypes
From Vanderbilt ABCDE educational module
ICU Delirium
• Increased ICU length of stay (8 vs 5 days)
• Increased hospital length of stay (21 vs 11
days)
• Increased time on ventilator (9 vs 4 days)
• Higher ICU costs ($22,000 vs $13,000)
• Higher ICU mortality (19.7% vs 10.3%)
• Higher hospital mortality (26.7% vs 21.4%)
• 3-fold increased risk of death at 6 months
Ely, et al. ICM2001; 27, 1892-1900
Ely, et al, JAMA 2004; 291: 1753-1762
Lin, SM CCM 2004; 32: 2254-2259
Milbrandt E, et al, Crit Care Med 2004; 32:955-962.
Ouimet, et al, ICM 2007: 33: 66-73.
From Vanderbilt ABCDE educational module
Mobility
Duke Initiatives
• Wake Up and Breathe (and redefine VAP)
• Early Mobility
• Patient Safety Education (in the professional
schools)
• Patient Centered Care
“SAT + SBT” Was Superior to
Conventional Sedation + SBT
Intervention (SAT) group = Less benzodiazepine
Extubated faster
Girard et al. Lancet 2008; 371:126-34
Discharged from ICU sooner
From Vanderbilt ABCDE educational module
“SAT + SBT” Was Superior to
Conventional Sedation + SBT
Better survival at 1 yr
Alive
Discharged from hospital sooner
Intervention (SAT) group = More unplanned
extubation, but not more reintubation
Girard et al. Lancet 2008; 371:126-34
From Vanderbilt ABCDE educational module
Early Exercise in the ICU
• Early exercise = progressive mobility
• Study design: paired SAT/SBT protocol
with PT/OT from earliest days of
mechanical ventilation
Wake Up, Breathe, and Move
Schweickert WD, et al. Lancet. 2009;373:1874-1882.
From Vanderbilt ABCDE educational module
Early Exercise Study Results
Schweickert WD, et al. Lancet. 2009;373:1874-1882.
Mobility- No excuses
Cardiopulmonary Phys The J 2012 March; 23(1):30-35
Mobility- No excuses
Cardiopulmonary Phys The J 2012 March; 23(1):30-35
Duke Data
• Protocol started 2.5 years ago
– Competencies for returning PT (ortho->MICU)
• Suctioning
• Familiarity with Duke protocol
• Mini-QI prior to start:
– 40-50% being seen by therapist (long delay in ordering; nurses
not activating order)
– PT/OT rounding with team did NOT work
• Post Protocol data underway
– % patients getting PT, how many times a day seen, highest level
of activity, etc.
– reasons not referred, % referred but not treated
– Delirium Screen
IPE: Patient Safety (PT and SON)
Team Training with the patient
True Patient Centered Care
Bad Disease
Many Health System Encounters
A little PTSD
Great Team (family and HS!)
Patient Centered Care
Health System invested in
Continual Improvement