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 12

X2 per day 24

X6 weeks >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

Girard et al. Lancet 2008; 371:126-34

Extubated faster Discharged from ICU sooner

From Vanderbilt ABCDE educational module

“SAT + SBT” Was Superior to Conventional Sedation + SBT

Intervention (SAT) group = More unplanned extubation, but not more reintubation

Discharged from hospital sooner Better survival at 1 yr

Aliv

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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

Schweickert WD, et al. Lancet. 2009;373:1874-1882.

Wake Up, Breathe, and Move

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

Great Team (family and HS!) Patient Centered Care Health System invested in Continual Improvement

Bad Disease Many Health System Encounters A little PTSD