the texas wake up and breathe quality improvement initiative: data collection activities terri...

The TEXAS Wake Up and Breathe Quality Improvement Initiative:

Data Collection Activities

Terri Conner, PhDNybeck AnalyticsProject Manager Texas Wake Up and Breathe Initiative

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Overall Initiative Purpose

Improve care for ventilated patients

– Improve sedative weaning

– Speed extubation

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Results of Observation Studies

Audits from across the country show that Spontaneous awakening trials (SATs) and

Spontaneous breathing trials (SBTs) are only initiated 50% of the time

SBTs not coordinated with SATs

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Benefits of coupled SATs and SBTs

time on ventilation up to 3 days time in hospital up to 4 days

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Texas Wake Up and Breathe Collaborative Structure

Designate champion

Baseline survey

– Please complete this at your earliest convenience and

return to Terri Conner at terri@nybeck.net

Monthly data submission and surveys

Monthly calls with our group

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Three tools

Monthly survey Daily data collection tool Monthly data submission

Monthly SurveyAll Teach, All Learn

Aim

Tests conducted

Outcomes

Lessons learned

Barriers / breakthroughs

Plans for next month

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Data Collection Efforts

Track performance Measure impact on outcomes

– LOS– Mortality– Antibiotic usage– VAC, IVAC, VAP rates

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SAT/SBT Performance Documentation

Clinical champions should oversee SAT/SBT documentation

Integrate into existing processes– Daily care plans– Checklists

Develop your own process

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Daily Data Elements

Excel spreadsheet tool Automatic calculation

– VAC– IVAC

Possible and probable VAP

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Outcome Definitions

VAC– Significant respiratory deterioration after >2 days

of stability

IVAC– VAC– abnormal temp or WBC count– >4 days of new antibiotics

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Outcome Definitions

Possible VAP– IVAC– Either purulent sputum OR + sputum/BAL culture

Probable VAP– IVAC– Both purulent sputum AND + sputum/BAL culture

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Daily Data CollectionVAC Status

Patient Date PEEPmin FiO2min VAC

1 1-Apr-12 10 100

1 2-Apr-12 5 60

1 3-Apr-12 5 40

1 4-Apr-12 8 50

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Daily Data CollectionVAC Status

Patient Date PEEPmin FiO2min VAC

1 1-Apr-12 10 100

1 2-Apr-12 5 60

1 3-Apr-12 9 50 VAC

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Daily Data CollectionIVAC Status

Tmin, Tmax, WBCmin, WBCmax

– Enter for a total of 5 days

– Start 2 days prior to VAC onset

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Daily Data CollectionIVAC Status

Pt Date Tmin

Tmax

WBCmin

WBCmax

QAD SigTemp

SigWBC

QADFlag

IVAC

1 1-Apr 37 37.5 6 8

1 2-Apr 37.5 37.8 6 8

1 3-Apr 37 38.3 6 14

1 4-Apr

1 5-Apr

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Daily Data CollectionIVAC Status

Pt Date Tmin

Tmax

WBCmin

WBCmax

QAD SigTemp

SigWBC

QADFlag

1 3-Apr

37 38.3 6 14 Yes

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Daily Data CollectionQAD Determination

QAD

– New antibiotic prescribed or continued– Includes days between doses at extended

intervals (> q 24 h)– Data are entered for up 10 days (4 days before

VAC, on the VAC dx day, and 5 days after VAC)

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Antibiotic WorksheetQAD Determination

Dose hour

-4 -3 -2 -1 VAC day 0

1 2 3 4 5

Levo 24 Y Y

Vanc Y Y

Vanclevel

Y

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Antibiotic WorksheetQAD Determination

Pt Dose hour

-4 -3 -2 -1 VAC day

0

1 2 3 4 5

Levo 24 Y Y

Vanc Y Y Y

Vanclevel

Y

QAD X X X X X X X

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Daily Data CollectionIVAC Status

Pt Tmin

Tmax

WBCmin

WBCmax

QAD SigTemp

SigWBC

QADFlag

IVAC

1 37 38.3 6 14 Yes 1 1 3 IVAC

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Daily Data CollectionPossible/Probable VAP Status

Enter sputum/BAL gram stain and culture results

– Polys

– Epis

– Culture

– Growth > Threshold

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Daily Data CollectionPossible/Probable VAP Status

Patient Date Polys Epis Culture Growth > Threshold

1 1-Apr-12 3 1

1 2-Apr-12 2 2 Enterococcus

1 3-Apr-12 2 1 Klebsiella Yes

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Daily Data CollectionPossible/Probable VAP Status

POLYS– Sputum or BAL gram stain polymorphonucleated

cells, neutrophils, or white blood cells– Enter 0 to 4

0: none 1: few, rare, <10 cells/lpf 2: moderate, >25 cells/lpf 3: many 4: abundant

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Daily Data CollectionPossible/Probable VAP Status

EPIS– Sputum or BAL gram stain epithelial cells or

squamous cells– Enter 0 to 4

0: none 1: few, rare, <10 cells/lpf 2: moderate, >25 cells/lpf 3: many 4: abundant

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Daily Data CollectionPossible/Probable VAP Status

Patient Date Polys Epis Culture Growth > Threshold

1 1-Apr-12 3 1

1 2-Apr-12 2 2 Enterococcus

1 3-Apr-12 2 1 Klebsiella Yes

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Daily Data CollectionPossible/Probable VAP Status

Patient Date Polys Epis Culture Growth > Threshold

1 1-Apr-12 3 1

1 2-Apr-12 2 2

1 3-Apr-12 2 1

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Daily Data CollectionPossible/Probable VAP Status

CULTURE– Enter the culture result

Growth > Threshold– Yes

> 105 CFU/mL for endotracheal aspirate > 104 CFU/mL for BAL > 103 CFU/mL for protected specimen brush Semi-quantitative equivalents also acceptable

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Daily Data CollectionPossible/Probable VAP Status

Patient Date Polys Epis Culture Growth > Threshold

1 1-Apr-12 3 1

1 2-Apr-12 2 2 Enterococcus

1 3-Apr-12 2 1 Klebsiella Yes

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Daily Data CollectionPossible/Probable VAP Status

Patient Date Polys Epis Culture Growth > Threshold

1 1-Apr-12 3 1

1 2-Apr-12 2 2 Enterococcus

1 3-Apr-12 2 1 Klebsiella Yes

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Daily Data CollectionPossible/Probable VAP Status

Patient Date Possible VAP

Probable VAP

Final Determination

1 1-Apr-12

1 2-Apr-12

1 3-Apr-12 Probable VAP

Probable VAP

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Monthly Data Report

Hospital LOS ICU LOS Hospital discharge status Ventilator days SAT days – ‘real time’ data collection SBT days - ‘real time’ data collection Self-extubated / re-intubated (optional) Outcomes (VAC,IVAC, poss/prob VAP)

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Monthly Data Report

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Main Street Hospital 1 20 8 A 5 4 2 n n y y y nMain Street Hospital 2 6 4 A 4 4 2 n n n n n nMain Street Hospital 3 13 9 A 7 6 6 n n y y n n

VAP -Possible

VAP -Probable

SAT days

SBT days

Self-Extubated (optional)

Re-Intubated (optional)

VAC IVACHosp

Discharge Status

Vent Days

Hospital IDPt

NumberHosp LOS

ICU LOS

Questions?

Repeat webinar on July 16th, 9am CT Please feel free to contact Terri at

terri@nybeck.net or Rachel at rhardegree@tha.org

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