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 Table of Contents  
EDITORIAL
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 1-4

One-year progress oa a large-scale collaborative project for improving the care of mechanically ventilated patients


1 Department of Intensive Care, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Department of Emergency; Department of Intensive Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Deputyship of Curative Services, Ministry of Health, King Saud Medical City, Riyadh, Saudi Arabia
4 Department of Intensive Care, King Saud Medical City, Riyadh, Saudi Arabia
5 Department of Intensive Care, King Abdulaziz Medical City, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
6 Department of Military Medical Services, Ministry of Defense, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
7 Department of Adult Critical Care, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
8 Department of Intensive Care Services, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
9 Deputyship of Curative Services, Ministry of Health, King Saud Medical City, Riyadh, Saudi Arabia; College of Medicine, Tanta University, Tanta, Egypt
10 Department of Intensive Care, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
11 Department of Emergency and Critical Care Medicine, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
12 Department of Quality and Patient Safety, King Abdullah International Medical Research Center, College of Medicine, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
13 Department of Intensive Care, King Saud University Medical City, Riyadh, Saudi Arabia
14 Department of Medical Services, King Abdulaziz Medical City, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
15 Department of Anesthesiology and Critical Care Medicine; Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

Date of Submission12-Feb-2020
Date of Acceptance16-Mar-2020
Date of Web Publication30-Apr-2020

Correspondence Address:
Yaseen M Arabi
Department of Intensive Care, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, ICU 1425, PO Box 22490, Riyadh, 11426
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sccj.sccj_11_20

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How to cite this article:
Arabi YM, Al Aseri Z, Alaama T, Alharthy A, Al-Hameed FM, Mandourah Y, Elhazmi A, Sallam H, Almekhlafi GA, Mady A, Alghamdi K, Alshahrani MS, Ghamdi A, Al Qasim E, I Abdukahil SA, Alzahrani AA, Al Qarni M, El-Rahman BA, Alkatheri M, Alsaawi A, Latif A, Berenholtz SM. One-year progress oa a large-scale collaborative project for improving the care of mechanically ventilated patients. Saudi Crit Care J 2020;4:1-4

How to cite this URL:
Arabi YM, Al Aseri Z, Alaama T, Alharthy A, Al-Hameed FM, Mandourah Y, Elhazmi A, Sallam H, Almekhlafi GA, Mady A, Alghamdi K, Alshahrani MS, Ghamdi A, Al Qasim E, I Abdukahil SA, Alzahrani AA, Al Qarni M, El-Rahman BA, Alkatheri M, Alsaawi A, Latif A, Berenholtz SM. One-year progress oa a large-scale collaborative project for improving the care of mechanically ventilated patients. Saudi Crit Care J [serial online] 2020 [cited 2020 Aug 6];4:1-4. Available from: http://www.sccj-sa.org/text.asp?2020/4/1/1/283639




  Introduction Top


The National Approach to Standardize and Improve Mechanical Ventilation (NASAM) project is a national collaborative quality improvement project in Saudi Arabia, which aims to improve the care of mechanically ventilated patients by implementing evidence-based practices with the goal of reducing the rate of ventilator-associated events (VAEs) and therefore reducing mortality, mechanical ventilation duration, and intensive care unit (ICU) length of stay.[1] The project has been launched on January 1, 2019. The objective of this article is to review the progress of the project in the last year and reflect on the milestones, achievements, as well as opportunities for improvement.

The project has been built around implementing bundles of evidence-based practice, including the use of subglottic suctioning, head of bed elevation, spontaneous awakening trials, and spontaneous breathing trials, which have been incorporated in the Assessing pain, Both spontaneous awakening and breathing trials, Choice of analgesia, Delirium management, Early mobility, and Family engagement (ABCDEF) bundle and minimization of sedation and avoidance of neuromuscular blockers, unless there is a clear indication.[2],[3],[4] Details of the project description have been described previously.[1]


  Comprehensive Unit-Based Safety Program Teams Top


NASAM utilizes the concepts of the Comprehensive Unit-Based Safety Program (CUSP), which is designed to help clinical teams make care safer by combining improved teamwork, clinical best practices, and the science of safety.[5] Participating ICUs in the NASAM project have formed CUSP teams. The teams consists of physicians, nurses, respiratory therapists, occupational/physical therapists, and, in some units, infection control practitioners, although there are some variations among different units. These teams hold internal meetings to review their unit's updates, progress, challenges, and ways to improve and drive change. They review reports of NASAM bundle compliance and take action plans. They escalate issues that require further actions to hospital administration. CUSP teams from different hospitals present their experiences in the bi-monthly webinars and share videos of early mobility as well as any established protocols. Most CUSP teams communicate through WhatsApp groups.


  Leadership Support Top


Recruiting executives as active team members is one of the components of the CUSP framework. For this project to reach its target, we first aimed to seek the support from the leadership of stakeholders, which involved multiple meetings and discussions. Engaging senior executives to partner with the staff at unit levels bridges the gap between senior management and frontline providers and facilitates system-level perspective on quality and safety challenges that exist at the unit level.[6] The support continuously provided by the executives of each participating health sector has been tremendous and fundamental in carrying out the project forward. High-level engagement meetings are done on a regular basis to provide updates, present reports, discuss issues and solutions, as well as plan for the next steps forward. The project is conducted as a collaborative work across six healthcare sectors in Saudi Arabia and in collaboration with the Armstrong Institute for Patient Safety and Quality. The leadership support in all participating sites was and remains instrumental in facilitating site enrollment and ICU staff engagement.


  Site Recruitment Top


Since its launch in January 2019, 78 ICUs from 48 hospitals in 27 cities have registered for the project. Site recruitment has been achieved through communications with the leadership of different health sectors. Communication through the Saudi Critical Care Society and the Saudi Critical Care Trials Group has been also instrumental. Direct communications with multidisciplinary teams across has helped in getting the buy-in from the frontline staff to serve as catalysts in bringing about change. Ongoing communication, via various platforms, including e-mails, telephone calls, web, and teleconferences as well as WhatsApp groups, has provided a continuous loop of communication.


  Workshop Top


A 2-day workshop was conducted on November 19–20, 2018. This was attended by multidisciplinary healthcare teams from different regions of the country. One of the workshop's aims was to launch of the project. Keynote speakers were invited to share their expertise in the different aspects of mechanical ventilation as well as patient safety.


  Website Top


A NASAM web portal (https://ngha.med.sa/English/eServices/nasam/Pages/default.aspx) was created to provide an educational platform for frontline staff; various resources are also available, including protocols, in addition to the NASAM YouTube channel where bi-monthly webinars are uploaded.


  Database Management Top


A NASAM electronic portal was created for data entry. Minimal data collection and entry are done twice per week. The database then shows real-time benchmarking graphs. All units have access to their performance graphs, and teams can track progress over time and compare data to benchmark against another unit from the same hospital, from the same health system, and with the whole cohort [Figure 1].
Figure 1: Example of audit report sent to sites

Click here to view


The graphs include process of care measures including use of subglottic suctioning, spontaneous awakening trial, spontaneous breathing trial, less frequent use of neuromuscular blockers, and early mobility. It also includes outcome measures including VAEs and mortality.


  Webinars and Training Top


The NASAM webinars are being held every other week. Through the webinars, the project is being reviewed with all units. In addition, teams were asked to share their experiences as well as their success stories. Recognizing and highlighting success stories provide boost to the frontline staff. Some outstanding achievements such as having highly functional CUSP teams and making progress on early mobility are presented from several participating teams. Further, the webinars serve as an educational venue to share best practices and protocols. For example, protocols for spontaneous awakening trials, spontaneous breathing trials, and use of subglottic suctioning are presented and discussed in the webinars.

Accurate data collection is an integral part of this project. Therefore, training sessions for the use of the database, VAE form data collection, and understanding the definition of each data component are all presented. Various topics have been discussed, including in-depth definitions of VAEs, early mobility, delirium, and the ABCDEF bundle.

For 2019, a total of 33 webinars (which includes bi-monthly scheduled and ad hoc webinars) have been conducted for the year.


  Measurements of Processes of Care and Outcomes Top


Audit and feedback

In addition to the real-time performance feedback and benchmarking through the NASAM platform, the management team generates monthly reports that are sent to each unit. Using this information, participating ICUs track their performance over time and compare their performance with others. The CUSP teams are asked to share reports with the team members, frontline staff, and hospital leaders to sustain engagement and to drive change. Additional feedback is also done through direct communication, phone, ad hoc webinars, and site visits to address issues and challenges.

Patient safety culture survey

The Hospital Survey on Patient Safety Culture is being used by the NASAM project to assess patient safety culture in participating sites. It was used once at the beginning of the project and is planned to be repeated to track change.[7]


  Future Plans Top


We plan to extend its implementation until December 31, 2020. We will continue to introduce the use of VAE measurements in hospitals not adopting to VAE. A key to success is to sustain the engagement of NASAM teams across all hospitals.


  Conclusion Top


Launching a national collaborative quality improvement project is progressing well in Saudi Arabia. Such project requires high level of collaboration and leadership support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arabi YM, Al Aseri Z, Alaama T, Alqahtani A, Alharthy A, Almotairi A, et al. National approach to standardize and improve mechanical ventilation. Ann Thorac Med 2019;14:101-5.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Pun BT, Balas MC, Barnes-Daly MA, Thompson JL, Aldrich JM, Barr J, et al. Caring for critically ill patients with the ABCDEF bundle: Results of the ICU liberation collaborative in over 15,000 adults. Crit Care Med 2019;47:3-14.  Back to cited text no. 2
    
3.
Klompas M, Branson R, Eichenwald EC, Greene LR, Howell MD, Lee G, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35 Suppl 2:S133-54.  Back to cited text no. 3
    
4.
Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJ, Pandharipande PP, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2018;46:e825-73.  Back to cited text no. 4
    
5.
The CUSP Method. Available from: https://www.ahrq.gov/hai/cusp/index.html. [Last accessed on 2020 Mar 10].  Back to cited text no. 5
    
6.
Agency for Healthcare Research and Quality. Engage the Senior Executive. Available from: https://www.ahrq.gov/hai/cusp/modules/engage/index.html. [Last accessed on 2020 Mar 10].  Back to cited text no. 6
    
7.
Ulrich B, Kear T. Patient safety and patient safety culture: Foundations of excellent health care delivery. Nephrol Nurs J 2014;41:447-56.  Back to cited text no. 7
    


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  In this article
Introduction
Comprehensive Un...
Leadership Support
Site Recruitment
Workshop
Website
Database Management
Webinars and Tra...
Measurements of ...
Future Plans
Conclusion
References
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