hap/vap care bundle interventions - a uk … care bundle interventions - a uk approach dr r g...

HAP/VAP care bundle interventions - a UK approach

Dr R G MastertonNHS Ayrshire & Arran

How Hazardous Is Health Care?

1

10

100

1,000

10,000

100,000

1 10 100 1,000 10,000 100,000 1,000,000

10,000,000

Number of encounters for each fatality

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REGULATEDHAZARDOUS(>1/1000)

ULTRA-SAFE(<1/100K)

Health Care

Mountain Climbing

Bungee Jumping

Driving

Chemical Manufacturing

Chartered Flights

Scheduled Airlines

European Railroads

Nuclear Power

(Leape and Amalberti)

Healthcare Quality Strategy• 3 Quality Ambitions

– Mutually beneficial partnerships between patients, their families and those delivering healthcare services. Partnerships which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.

– No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times.

– The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.

Healthcare Quality Strategy• 3 Quality Ambitions

– Mutually beneficial partnerships between patients, their families and those delivering healthcare services. Partnerships which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making.

– No avoidable injury or harm from the healthcare they receive, and that they are cared for in an appropriate, clean and safe environment at all times.

– The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, with no wasteful or harmful variation.

Person centred

Harm

Waste & Variation

Quality Measurement Framework

Quality Outcome Measures

HEAT

Supporting local and national quality indicators

1 2 3 4 5

QUALITY INITIATIVES COST REDUCTION PROGRAMMES

Costs more Cost neutral Improves quality Quality neutral Reduces qualityreduces costs

3

Healthcare Quality & Cost

“To do things differently, we must see things differently. When we see

things we haven’t noticed before, we can ask questions we didn’t know to

ask before.”

John Kelsch, XeroxQuality Health care in America Project

Care Bundle

HAP Guideline RecommendationsGrade Prevention Diagnosis Treatment

A 11 5 5

B 10 0 6

C 9 5 3

D 8 2 3

GPP 60 6 10

Masterton et al. J Antimicrob Chemother. 2008;62:5-34.

1. Set of around 5 evidence-based interventions that apply to all patients with a common disease.

2. Ensure the delivery system means the interventions are delivered.

3. Compliance is “all” or “nothing.” 4. Measure outcomes to ascertain benefits.5. Develop the will to deliver “all the time every

time”.

Masterton. Intensive Care Med. 2009;35:1149-51.

What is a “Care Bundle”?

Success of Care Bundles in Healthcare Environment

• Institute of Healthcare Improvement ‘100K Lives Campaign’ in USA has now become the ‘5 Million Lives Campaign’

Care Bundles demonstrated to be highly effective:– Central Line Bundle has reduced bloodstream infections– Ventilator Bundle has reduced ventilator associated pneumonia

• Care Bundles to prevent HCAI are advocated High Impact Interventions in the Department of Health ‘Saving Lives’ delivery programme

Seven Care Bundles published to date:– Most for insertion/care of indwelling catheters/devices– Care Bundle for prevention of spread of Clostridium Difficile includes an

element for prudent antibiotic prescribing

Severe Sepsis Bundles

•Bundle use = consistent and significant improvement in survival•Antibiotic administration, timing and appropriateness = maximum outcome benefit.

Khan et al. Indian J Crit Care Med. 2010 ;14: 8–13

• The New Treatment Paradigm

• VAP Care Bundle

• Antimicrobial Care Bundle

THE NEW TREATMENT PARADIGM

The New Treatment Paradigm• Start with the appropriate empiric antibiotic first

in nosocomial infections• If appropriate, change antibiotic dosage or

therapy based on resistance and pathogen information

• Recognise that prior antimicrobial administration is a risk factor for the presence of resistant pathogens

• Know the unit’s resistance profile and choose antibiotics accordingly

• Administer antibiotics at the right dose for the appropriate duration

Masterton. Int J Antimicrob Agents. 2009 ;33:105-110.

Rello et al. Crit Care Med 2003;31:2807–2808

Septic shock0

10

20

30

40

50

SepsisSevere shock

43

2320

Improved survival rate (%)

Getting it right……………

The Clock is ticking……………

0102030405060708090

0.5 1 2 3 4 5 6

Delay in treatment (hours) from hypotension onset

Surv

ivia

l (%

)

Each hour off delay carries 7.6% reduction in survival

Kumar et al. Crit Care Med 2006; 34:1589-1596.

The New Paradigm in a Care Bundle

• Secondary analysis of prospective before–after study

• Intervention: emergency department sepsis bundle

• Bundle components– Patient identification– Fluid resuscitation– Vasopressor administration– Antibiotic recommendations

Shorr, et al. Crit Care Med 2007;35:1257–1262

p=0.009

0

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Cost

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ient (

US $)

GroupBefore After

Mortality reduced with protocol from 48.3% to 30.0% (p=0.04)

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$)

Group

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40 000

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Before After

Total group Survivors



Total cost differential: $573,000

0

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800

1,200

1,600

2,000

Total ICU Ward Pharmacy Lab Rad RT ED OR Misc

Costs

(US$

x 10

00)

Before After



Median LOSPre: 10 daysPost: 7.5 days

Prop

ortio

n of s

ubjec

tsre

maini

ng ho

spita

lised

p=0.0023

0.0

0.2

0.4

0.6

0.8

1.0

0 10 20 30 40Length of stay (days)

Pre-interventionPost-intervention



VAP CARE BUNDLE

The “Care Bundle” Approach

• VAP Care Bundle– 5 simple, basic, universally accepted

components• Bed elevation• Sedation vacation• Daily weaning assessment• Peptic ulcer prophylaxis• DVT prophylaxis

Craven. Chest;2006;130:251-260

VAP Care Bundle – The Top Ten

600 620 640 660 680 700 720

De-escalate in responding patients once culture results available

Monotherapy in preference to combination therapy in those not at risk for pseudomonas or MDR

Sedation vacation and weaning protocol

Short duration of treatment therapy - 8 days if patient on appropriate regimen and not infected by MDR pathogen

Assess response within 72 hours

SD for mechanically ventilated patients greater than 48 hours

Non invasive ventilation preferred

Oral care with chlorhexadine

Immediate treatment following microbiological sampling

Empiric therapy based on knowledge of local pathogens and assessment of risk factors

PreventionDiagnosisTreatment

Rello et al. J Crit Care. 2010 May 26. [Epub ahead of print] & Intensive Care Med. 2010;36:773-80.

VAP Care Bundle Treatment

600 620 640 660 680 700 720

De-escalate in responding patients once culture results are available

Monotherapy in preference to combination therapy in those not at risk for pseudomonas or MDR

Short duration of treatment therapy - 8 days if patient on appropriate regimen and not infected by MDR pathogen

Assess response within 72 hours

Immediate treatment following microbiological sampling

Empiric therapy based on knowledge or local pathogens and assessment of risk factors

Rello et al. J Crit Care. 2010 May 26. [Epub ahead of print] & Intensive Care Med. 2010;36:773-80.

Impact of IHI VAP Improvement Bundle

The key components of the Ventilator Bundle are:

1. Elevation of the Head of the Bed 2. Daily "Sedation Vacations" and Assessment

of Readiness to Extubate 3. Peptic Ulcer Disease Prophylaxis 4. Deep Venous Thrombosis Prophylaxis5. Daily Oral Care with Chlorhexidine

Al-Tawfiq et al. Am J Infect Control. 2010 Apr 17. [Epub ahead of print].

• VAP prevention bundle resulted in reduction of VAP rates from (P < .001) :– Mean of 9.3 cases/1000 ventilator-d in 2006 – Mean of 2.3 cases/1000 ventilator-d in 2007– Mean of 2.2 cases/1000 ventilator-d in 2008

• Each VAP case increased:– attributable hospital LoS by 10 days– mean hospital cost by $40,000.


Impact of IHI VAP Improvement Bundle

1. Elevation of the Head of the Bed to 30˚

2. Daily Sedation Break

3. Discussion of Extubation and Weaning

4. Daily x4 Oral Care with Chlorhexidine


VAP Care Bundle in The Ayr Hospital

VAP in The Ayr Hospital

ANTIMICROBIAL CARE BUNDLE

The Antimicrobial Care Bundle• At initiation:

– Document clinical rationale for antibiotic initiation

– Appropriate specimens sent to diagnostic microbiology laboratory (according to local policy)

– Antibiotic selected according to local policy and risk group (exclude allergy)

– Consider removal of foreign body/drainage of pus/surgical intervention

Cooke et al. Int J Antimicrob Agents. 2007;30: 25–29.

The Antimicrobial Care Bundle

• For continuation:– Daily consideration of:

• de-escalation• intravenous–oral switch• stopping antibiotics (based on review of clinical picture

and laboratory results)

– Antibiotic drug levels monitored as required by local policy

Cooke et al. Int J Antimicrob Agents. 2007;30: 25–29.

The Antimicrobial Stewardship Bundle

• Documentation of treatment rationale• Collection of appropriate specimens• Appropriate empirical selection of

antibiotics according to local surveillance and formulary

• De-escalation• Selection of appropriate agents for

definitive therapyToth et al. American Journal of Health-System Pharmacy, 2010;67: 746-749.

• A total of 160 patients and 442 antibiotic orders were evaluated.– 168 interventions were made, with an

acceptance rate of 91%. – De-escalation rose from 72% to 90% (p = 0.01). – Compliance with all quality indicators rose from

16% to 43% (p < 0.001).

Toth et al. American Journal of Health-System Pharmacy, 2010;67: 746-749.

The Antimicrobial Stewardship Bundle

Success Through EducationThe Change Team

Bloos et al. British Journal of Anaesthesia 2009;103: 232–7 .

Success Through EducationThe Change Team

Bloos et al. British Journal of Anaesthesia 2009;103: 232–7 .

•No difference in VAP frequency Audit I (33.1%) and Audit II (32.4%, P=0.68).

Success Through FeedbackThe Electronic Dashboard

Zaydfudim et al. Arch Surg. 2009;144(7):656-662.

Success Through “MMP”The Multimodal Programme

Hawe et al. Intensive Care Med. 2009;35:1180-6.

Multimodal programme = staff education, process measurement , outcome measurement, feedback to staff and organisational

change.

• VAP prevention bundle compliance increased after active implementation.

• VAP incidence fell significantly from 19.2 to 7.5 per 1,000 ventilator days. • Rate difference (99% CI) = 11.6 (2.3-21.0) per 1,000 ventilator days; • Rate ratio (99% CI) = 0.39 (0.16, 0.96).

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make that will result in improvement?

Act Plan

Study Do

When you combine the 3 questions with the…

PDSA cycle, you get…

…the Model for Improvement

Success Through the IHI ToolThe Model for Improvement

hap/vap care bundle interventions - a uk … care bundle interventions - a uk approach dr r g...

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