Conflict of Interest Disclaimer. The Affordable Care Act. The Affordable Care Act. Caring for the Critically Ill. The Affordable Care Act

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1 Conflict of Interest Disclaimer Reducing Risks of Harmful Events in the Critically Ill I have no financial interests or conflicts of interest related to this talk Alfred F. Connors, Jr., MD Chief Medical Officer, The MetroHealth System Senior Associate Dean, CWRU SOM The Affordable Care Act Most citizens will have health insurance Medicaid will be expanded to % of FPL Individuals with income % to % FPL eligible for insurance exchanges About million new insured individuals These are clearly good things The Affordable Care Act Increased coverage will increase cost Strategy for covering these costs: Pressure on health care system to: Improve health Improve care Lower costs Reduced reimbursements New fees and taxes Eliminate fraud and waste The Affordable Care Act Emphasis on measuring quality and reporting outcomes Improve patient safety Reduce medical errors Prevent readmissions Manage costs Increase efficiency of care and services Caring for the Critically Ill ICUs are a very high cost environment High cost per day (FTEs and facilities) High cost for treatments High cost for labs and imaging High risk for preventable harm (% ICU) Ventilator associated pneumonia (%) Catheter associated bloodstream infections (%) Catheter associated urinary tract infections (%) Medication errors

2 Caring for the Critically Ill ICUs are a very high cost environment High cost per day (FTEs and facilities) High cost for treatments High cost for labs and imaging High risk for preventable harm Ventilator associated pneumonia Catheter associated bloodstream infections Catheter associated urinary tract infections Medication errors Epidemiology of CRBSI, nosocomial bloodstream infections per year % of these are primary infections % nosocomial BSI occur in the ICU Most are catheter associated About, CRBSI in ICUs each year Related to, deaths $. billion Epidemiology of CRBSI Attributable Mortality Variable results: to % Odds ratio, adjusted.. Attributable LOS ICU LOS*. (..) days Hospital LOS*. (..) Attributable Costs* $, ($,-$,) Preventing CRBSI: Insertion Use CV catheter only when needed Excellent hand hygiene Maximal barrier precautions at insertion Disinfect skin with % chlorhexidine prep Sterile gauze or semipermeable transparent dressing *Warren et al, CCM ; : 9 Preventing CRBSI: Management Replacement of administration kits >h Exceptions: blood, blood products, lipids Clean injection ports with % EtOH or iodophor with each access Replace dressing when damp, soiled or not occlusive Remove catheters when no longer essential Pronovost et al. NEJM ;: Prospective cohort study Before and after, observational design ICUs in Michigan 9 ICU months, catheter days Outcome: CRBSI / catheter days Measured at three month intervals

3 Pronovost et al Intervention Team leader and clinicians educated Partner with infection control practitioner Five evidence based procedures Hand hygiene Full barrier precautions at insertion Skin cleaning with chlorhexidine Avoid femoral site Remove unnecessary catheters Pronovost et al Intervention Central line carts with all supplies Checklist to assure compliance Providers stopped if process not followed Catheter removal discussed at daily rounds Monthly feedback to teams number and rates of CRBSI Pronovost et al Results (CRBSI/ catheter days) Mean Before. CRBSI/ days months. CRBSI/ days Median Before. CRBSI/ days months. CRBSI/ days Incident rate ratio:. (..) Marsteller et al Marsteller et al CCM ;:9 Multicenter, phased, cluster-randomized controlled trial ICUs from hospitals in two systems Intervention: Pronovost bundle, checklist, observer Comprehensive, unit-based, safety program Compare at 9 months, then all in Marsteller et al Results (CRBSI/ catheter days) Mean Study Control N (ICUs) Baseline.. 9 months.. months.. Incident rate ratio:.9 (..) Consistent results! st Author Design Site Pronovost NEJM/BMJ Marsteller CCM De Palo QSHC Lin AJMQ Base line - mo - mo B A MI... RCT System..9 B A RI.. B A HA..

4 Epidemiology of VAP Incidence of VAP Observational (): % ( %) RCTs (): % (9 -%) Attributable Mortality* Variable results: to % Best studies: % to % Attributable LOS*. (. to.) days Attributable Costs* $, ($, - $,) Preventing VAP General prevention Non-invasive ventilation when possible Strict hand hygiene Avoid over sedation (protocols and daily sedation interruption) Daily weaning readiness assessment Weaning protocol Extubate promptly 9 Preventing VAP Prevent aspiration Semi-recumbent position, o to o Subglottic suctioning ET cuff pressure at least cm HO Reduce colonization of upper airway Regular oral care with antiseptic solution Selective digestive track decontamination* Preventing VAP Reduce colonization of upper airway Avoid nasotracheal intubation Regular oral care with antiseptic solution Selective digestive track decontamination* Reduce contamination from MV equipment Remove condensate from vent circuits Change circuit only when soiled Disinfect and store equipment properly Reducing VAP in the ICU Berenholtz et al, Inf Control Hosp Epidemiol ;: Prospective cohort study Before and after, observational design ICUs from hospitals in Michigan ICU months, ventilator days Outcome: VAP / ventilator days Measured at three month intervals Reducing VAP in the ICU Berenholtz et al, Inf Control Hosp Epidemiol ;: Comprehensive unit-based safety program VAP bundle Semirecumbent positioning Stress ulcer prophylaxis DVT prophylaxis Sedation adjusted daily until patient can follow commands Daily assessment of readiness to extubate

5 Reducing VAP in the ICU Berenholtz et al, Inf Control Hosp Epidemiol ;: Mean VAP/d rate ratio Before.9. - months.. (. -.) - months..9 (. -.) Median Before. - months. - months. Reducing VAP in the ICU CCCTG CCM ;: Two year, prospective time series study ICUs patients (/ months) VAP guideline recommendations Multifaceted intervention Education, reminders, opinion leaders, and implementation teams Outcomes concordance and VAP rates Reducing VAP in the ICU CCCTG CCM ;: VAP rate (events/ patients) Periods - months /.% - months /.% Months /.% 9 months 9/.% % reduction in VAP (p =.) Reducing VAP in the ICU Pogorzelska et al, I J Qual Hlth Care ;: Cross sectional survey of VAP bundle use ICUs in hospitals Mean VAP rate =./ vent days (%) had VAP bundle policy (%) monitored compliance (%) reported high compliance Unless policy AND monitoring AND high compliance, no effect on VAP rate Cost of VAP/CRBSI prevention Waters et al, Am J Med Qual ;: hospitals from the Keystone ICU project Cost of program/hosp: $, CRBSI averted/hosp: 9.9 VAP averted/hosp:. Cost per infection averted: $, Estimated cost savings Per VAP: $, ($, - $,) Per CRBSI: $, ($,-$,) Concerns about the bundles Need RCTs of bundles to demonstrate effect on mortality, LOS, cost Do we have the right stuff in the bundle VAP: subglottic suction, daily oral care, SDD, silver impregnated tubes, etc. BSI: daily chlorhexidine baths, antibiotic impregnated lines, etc. Should be part of a comprehensive safety and quality program 9

6 VAP/CRBSI prevention: Does it save lives? Population attributable fraction Fraction of patients who would not have died if the infection had not occurred. Januel et al Inf Cont Hosp Epidemiol ;:.% of deaths for VAP/CLBSI/BSI.% VAP alone and.% CLBSI alone.%vap & other and.% CLBSI & other Only.% of deaths due other BSI or CAUTI Bekaert et al AJRCCM ;:.9% (.-9.%) VAP at days VAP prevention: Does it save lives? Muscedere, Day, Heyland CID ;:S Excellent meta-analysis 9 trials evaluating ICU mortality using a case control methodology, random effects model Odds ratio (ICU mortality associate with VAP).9 (..) Absolute attributable mortality.% (% - %) VAP prevention: Does it reduce LOS and vent days? Muscedere, Day, Heyland CID ;:S Excellent meta-analysis of VAP case-control studies Attributable prolongation of ICU stay. (. -.) days Attributable prolongation of hospital stay. (9.9 -.) days Attributable prolongation of vent days. (..) days CRBSI prevention: Does it reduce costs? Vrijens et al J Hosp Inf ;: Attributable prolongation of hospital stay 9.9 (..9) Days Attributable cost 9 ( - ) HAI # Preventable # Lives saved CLABSI,,,,9 VAP 9,,, 9, CAUTI 9,,, 9, SSI,,,, Total,9,,, HAI # Preventable Costs (x $B) CLABSI $.9. VAP $.9. CAUTI $.. SSI $. -. Total $.. Umscheid et al, Inf Cont Hosp Epidemiol ;: Umscheid et al, Inf Cont Hosp Epidemiol ;:

7 VAP/CRBSI prevention: Should we do it? Does VAP/CRBSI prevention save lives? YES Does VAP/CRBSI prevention reduce time in the ICU and in the Hospital? YES Does VAP/CRBSI prevention reduce health care costs? YES VAP/CRBSI prevention: Should we do it? If we can do it we should do it. Reducing HAI at MetroHealth. Hand Hygiene late to present. Isolation Procedures to present. Environmental Cleaning to present. Sterilization PI to present. High Level Disinfection PI - to present. Flash Sterilization PI to present. Antibiotic Stewardship to present. Evidence Based HAI protocols - rd qtr 9. Mandatory influenza vaccination to present. Culture of Safety to present -- BOT and CEO buy-in -- System wide awareness and involvement. Clear Goals and beyond Hand Hygiene Compliance Rolling weeks Data Report January, to March, % %% %% %%% 99% 99% %%%% % % %%%%%% % %% % % 99% 9% 99% 99% 9%9% 9% 9% 9% 9% 9% % % % % A B C B C A B C A B C S A B C B B C 9B 9C ED HD B C B C ANT CD L&D PA POp PP N N N Gra Hand Hygiene Compliance Rolling weeks Data Report January, to March, Monthly Hand Hygiene Compliance for % 9.% 9.% 9.% 9.9% 9.% 9.% 9.9% 9.% 9.% 9.% 9.% 9.% % 9% % 99% 9% % % % 99% % 99% 9% 9% % % % % % % Compliance for the = 9.% Total Number Observation =,9 % MD RN Other NA RT PT Diet HSK CM/SW Total %C % Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

8 % Monthly Hand Hygiene Compliance for 9.% 99.% 99.% 9.9% 9.% 9.% 9.% 9.% 9.% 9.% 9.% % 9% 9% 99.% - Total Hand Hygiene Compliance by Location 99.% 99.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.9% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9% % % % % % % % % % % Compliance for the = 9.% Total Number Observation =, Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec % % S C ANT CDU A PPCU A A B B C C A B B A C C B C B L&D A B B PAC 9C C C 9B C HD B ED pop % Isolation PPPE Compliance February to February Isolation PPPE Compliance By Provider Type February to February % 9% 9% % % % % % % % B C B C A B B C A B C A B C S A C A B C A B C 9B % 99% 9% 9% 9% % % % %% 9% 9% 99% 99% % 99% 9% 99% 9% %% 9% 9% % 9% % % %% % % 9% %% % 9C HD ED L&D PAC U ANT CDU E 9C PRE OP NICU N % MD RN RT HSK DIET PT OTH Nrs All Rest NA Total % % 9% 9% % % % % 99% 9% % 9% Room Cleaning Upgraded discharge & daily room cleaning Consistent processes and equipment Improved OR and equipment cleaning Improve monitoring of performance Consistent monitoring, testing and inspection Excellent teaming between IC and EVS Enhanced cleaning of MDR rooms at D/C Hydrogen peroxide vapor for MDR rooms Improved patient safety Improved perceptions of cleanliness Sterilization and High Level Disinfection Sterilization Sterilization at sites on and off campus Developed standards, audit performed sites closed due to inadequate facilities, equipment or processes remain with >9% compliance with standards High Level Disinfection of sites meeting standards closed, resolving issues with ventilation

9 Flash Sterilization Flash Sterilization 9 Antibiotic Stewardship Team () Goals Increase appropriate use of antibiotics Use fewer antibiotics Reduce days on multiple antibiotics Benefits Fewer patients with MDRO Reduce cost of isolation and Tx of MDRO Reduce infections caused by MDRO Reduce antibiotic costs DOT = Days of Therapy FQ = fluoroquinolone to : saved $,; % Hospital-Acquired, Serious Resistant Organisms, to ESBL pathogens Carbapenem resistant pathogens MDR Acinetobacer 9 DOT = Days of Therapy FQ = fluoroquinolone % reduction to 9

10 HAI Prevention Processes () Catheter-related bloodstream infections (CLBSI) Central line insertion supply kit Central line insertion check list Consistent daily insertion site care Ventilator Associated Pneumonia (VAP) VAP prevention bundle & order set Symptomatic catheter- associated urinary tract infections (CAUTI) UTI prevention bundle Number of infections Catheter Related Bloodstream Infections (CLBSI), to.9*.* *infections per catheter days.* ICU Non-ICU 9 Total Hospital Acquired Catheter Related Bloodstream Infections (ICU and non ICU, to ) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 9 Aug Sep Oct Nov Dec Number of infections Ventilator Associated Pneumonia (VAP) to.*.9* *pneumonias per ventilator days VAP 9.9* Ventilator Associated Pneumonia to Catheter Associated Urinary Tract Infection (CAUTI) to.* *infections per catheter days Infections/Month Number of Infections.*.* CAUTI 9

11 9 Catheter Associated Urinary Tract Infections (CAUTI) (ICU and non ICU).%.%.% Surgical Site Infection rate, All CMS Categories 9 to.% -%.% -%.% -% Infections/Month 9.%.%.%.%.% / /9 / / 9 % Reduction 9 to Mandatory Influenza Vaccination Vaccinations, employees + volunteers/contractors, vaccinated (99.%) Exemptions given to employees (.%) Serious allergic reactions to vaccine Serious acute reactions to vaccine Guillian-Barre Syndrome Deeply-held religious, ethical or moral beliefs Employees with exemptions wear masks during flu season Conclusions The ICU is a costly site of care with high risk of hospital acquired infections (HAI). to 9% of the cost and harm to patients from HAI is related to VAP and CRBSI. to % of VAP and CRBSI are preventable. Prevention of VAP/CLBSI will save many lives and substantial resources. All ICUs should implement high compliance VAP and CLBSI prevention programs ASAP. Vision, Goals, and Objectives Vision: The MetroHealth System will be in the top % of US hospitals for patient and employee safety. Goals: MetroHealth will eliminate preventable harm for the most common categories of harmful events* by //. Objectives: Evidence based prevention programs for these harmful events* will be implemented by //. Compliance with these programs will be consistently above 9% for all prevention programs by //. The number and rate of harmful events will be monitored to assure optimal reduction of harmful events* to a rate consistent with the elimination of preventable harmful events by //. Targeted Preventable Harmful Events* Ventilator associated pneumonia Central line associated bloodstream infections Symptomatic catheter associated urinary tract infections Surgical site infections Patient falls with significant injury Hospital acquired pressure ulcers, stage & Drug errors with significant harm Significant adverse events at childbirth Reduce early elective deliveries Hospital acquired thrombotic and embolic events Employee days of work missed due to work-related injury Approved BOT //