NYSPFP HAI (VAP) and the Patient
Transcription
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